N.B. All questions must be answered in full. Dashes are not acceptable. Please use BLOCK letters or tick as applicable.

Name of Agent/Broker

Name of the proposer (in full)

Postal Address P.O. Box Town

Telephone

Profession or Occupation (Nature of business)

Period of Insurance: From To

PIN Number (Attach copy of certificate)

Registered Mark

Chassis No. & Engine

No.

Make and Type of

Body

Engine Capacity In

Cubic Tonnes

Year of Manufacture

Colour of Vehicle/Is it

metallic

Carrying Capacity

passenger limit

Proposer’s estimate of

present market value including

Accessories

1. Tick the type of cover required: Comprehensive Third Party Fire and Theft Third Party Only

Note: For Comprehensive and Third Party Fire and Theft, the basis of settlement is the ‘market value’. This should be taken in to account when deciding the sum insured.

2. (a) Do you want to insure any accessory of the car?

If YES, give details and value

(b)Windscreen and window glass: Do you want additional cover if breakage occurs but no other damage is sustained by your vehicle? If YES, state the limit of cover required KSh. Note: Claims will be accepted up to the limit stated without loss of ‘No Claim Discount’ or deduction of excess.

MAYFAIR INSURANCE COMPANY LIMITED 8TH FLOOR MAYFAIR CENTRE, RALPH BUNCHE ROAD

P.O. BOX 45161 – 00100, NAIROBI, KENYA

TEL: +254 20 2999 000, FAX +254 20 2999111 MOBILE: +254 733/724 256925

EMAIL: info@mayfair.co.ke

PRIVATE CAR INSURANCE PROPOSAL FORM

PARTICULARS OF THE PROPOSER

PARTICULARS OF VEHICLE

PARTICULARS OF COVER

YES NO

YES NO

3. Has the vehicle(s) been fitted with approved anti-theft devices? If YES, attach certificate of fitting

4. Has the vehicle (s) been modified, altered, adapted or fitted with any additional equipment above the makers standards? If YES, give details

5. Are you the owner of the vehicle(s)?

If NO, state name and address of owner(s)/hire purchase company

6. Do you or does any other person who to your knowledge will drive the vehicle, suffer from defective vision or hearing from any physical infirmity?

If YES, give details:

7. Have you or has any other person who to your knowledge will be driving the vehicle,

been convicted of any offence in connection with the driving any motor vehicle or is any prosecuting pending? If YES, give details (include dates and nature of penalty)

8. Has any Insurance Company either in respect of yourself or any other person who will drive ever:

(i) Declined your or their proposals?

(ii) Required you or them to bear the first portion?

(iii) Refused to renew or cancelled your or their policy?

(iv) Required an increased premium or imposed other special conditions?

If the answer to any of the above questions is YES, give details:

9. Are you now or have you ever been insured in respect of any motor vehicle?

If YES, give details of insurer’s, policy number and registration number of vehicle(s)

1. Give records of accidents and/or losses during the past three years in connection with any motor vehicle

owned or driven by yourself or those who to your knowledge will be driving the vehicles insured under this

policy, whether insured or uninsured including any claim outstanding:

2. (i) Are you entitled to a No Claim Discount?

(ii) If YES, for how many years up, to date, have you previously been insured continuously without claim and

with which companies?

Note: To qualify for Discount submit renewal invitation or N.C.B letter from your previous insurer

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

CLAIMS EXPERIENCE

3. Will the vehicle(s) be used exclusively for social, domestic and pleasure puproses? If NO, state for what purpose it may be used:

4. (i) Do your undertake cartage for other persons?

(ii) Will the vehicle be used for hire or reward?

(iii) Will passengers be carried for hire or reward?

If the answer to any of the above questions is YES, give details

Note: The following extensions are available on payment of additional premium

Do you require cover for legal liability to passengers?

If YES, how many passengers?

Do you require over for personal accident to passengers?

If YES, how many passengers?

Do you require an increased Third Party Property Damage cover?

If YES, what is the amount required?

Do you require an increased medical expenses cover?

If YES, what is the amount required?

Do you require an increased towing expenses Cover?

If YES, what is the amount required?

Do you require Special Perils Cover Extension?

Do you require Strike and Riots Cover Extension?

I/We desire to insure with the Mayfair Insurance Company Limited, the motor vehicle(s) described in the above and

I/We hereby warrant that the above statements and particulars are true, and I/We have not suppressed,

misrepresented or misstated any material fact and I/We agree that the declarations shall be the basis of the contract

between Me/Us and the Company.

I/We further agree that if this proposal in any particular is filled by any other person, such person shall be deemed

My/Our agent and not the agent of the company. I/We further declare that I/We have read and understood all

particulars entered herein and I/We have signed this after verifying the same to be true and complete in all respects.

Date of Proposal _____________________ Signature and Stamp of proposer ________________________________

FOR OFFFIAL USE ONLY

Branch Manager/Authorise Person(s) signature Date

EXTENSIONS TO THE POLICY

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

DECLARATION

THE LIABILITY OF THE COMPANY DOES NOT COMMENCE UNTIL THE PROPOSAL HAS

BEEN ACCEPTED AND THE PREMIUM HAS BEEN PAID

YES NO

YES NO

YES NO

YES NO